Provider Demographics
NPI:1184397770
Name:BENFORD, SPENCER E
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:E
Last Name:BENFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8270 WILLOW OAKS CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4530
Mailing Address - Country:US
Mailing Address - Phone:281-716-5756
Mailing Address - Fax:
Practice Address - Street 1:8115 GATEHOUSE RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1203
Practice Address - Country:US
Practice Address - Phone:832-236-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202010062235Z00000X
TX116103235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty